Transcript Just Culture

Just Culture
NH Quality Assurance Commission
July 31,2009
Objectives
• Provide basic overview of Just Culture
• Examples through Storytelling
• Questions & Answers
Why do we need Just Culture?
Finding Accountability Balance
Concepts to Know
Behaviors
Duties
Core Beliefs of Just Culture
• We all make mistakes
• We tend to drift from what we are
taught
• Our sense of risk diminishes over
time when no adverse outcomes
occur
• We are accountable for actions
regardless of the outcome
• We must use our values to
evaluate behaviors and systems
Human Error
Response to HE
• We are fallible
• We must expect error
Console
• We must examine our
systems in terms of choices
Learn
employees make that can
increase risk. (forced functions)
• Systems are designed to
get the results they yield
At Risk Behavior
• Highway Driving
• Do you always drive the Speed
Limit?
• Do you always stay a few car
lengths away?
• Hand Washing
• Do people always perform hand
hygiene in between patients?
• Food in clinical areas
• Do you always avoid having coffee
at the Main Nursing Desk?
Response to ARB
Coach
Learn
Reckless Behavior
• Behavioral Choice to
consciously disregard a
substantial and unjustifiable
risk.
• Having knowledge that
harm is practically sure to
occur.
• Performing a procedure without
scrubbing in and draping per
standards
• Treating and caring for patients
while intoxicated or impaired by
drugs.
Response to RB
Punish
Duties of Organization and
Employees
Duty to Produce an Outcome
(system largely controlled by the employee)
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Be to work on time
Bring badge; Wear badge
Don’t steal
Don’t sexually harass
Don’t use profanity at work
Don’t look in medical records that aren’t
your business
Duty to follow Procedural Rules
(system largely controlled by employer)
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Two patient identifiers
Hand hygiene
Pump repair
Dietary protocols
Patient restraint
Medication administration
Accounting controls
Controlled substance discrepancies
The Duty to Avoid Causing
Unjustifiable Risk or Harm
(placing organizational value or interest in harm’s way)
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Do the right thing for the patient
Do the right thing for coworkers
Do the right thing for the family and visitors
Do the right thing for the organization
Behavior and Actions
CONTINUOUS LEARNING
Case #1
• Jenna RN works on a very busy Medical Surgical Unit.
Jenna is a seasoned nurse with 10 years experience. She
has worked for Metropolis Medical Center for 5 years.
• She currently has 4 patients and expecting an admission
within 15 minutes. She is in with Mrs. Jones performing a
difficult wound care and dressing change.
• The Student nurse comes in and reminds her that Mr.
Johnson’s medications are 25 minutes late.
• Jenna is feeling pressured and knows she will have a
Medication Error but also will be another 15 minutes with
Mrs. Jones.
• Jenna gives the student her PYXIS password and ask if the
Student will get Mr. Johnson’s medication and work with
her instructor to administer the medication.
• While in the Medication Room the Pharmacy Technician
witnesses the Student access PYXIS.
Other Facts
• Hospital established a policy forbidding the
sharing of personal passwords to all clinical
computer systems 6 years before.
• Jenna was educated on policy at orientation and
it is part of the hospitals annual HIPAA training
• There are four other RN’s working with Jenna
and 3 Care Tech’s
• Jenna has never been disciplined for anything
before. She admitted to giving other passwords
to people when she was in a bind, but never
considered it a big deal.
• The day after Jenna shared her password there
was a discrepancy in the controlled substances.
Duty to Follow Procedure
Was the duty
to follow the
procedure
known to the
employee?
YES
Was it
possible to
follow the
rule?
YES
Did she
knowingly
violate
the rule?
YES
Did the
social
benefit
exceed the
risk?
NO
Coach Employee
and conduct
further at-risk
behavior
investigation
Social Benefit –
Would the greater
good be served?
YES
Did the employee have a
good faith but mistaken
belief that the violation
was insignificant or
justified?
Case #2
• Ken works as the unit coordinator in a busy CCU/Telemetry
unit. His desk is surrounded by computers and monitors.
• Under the desk is a tangle of wires connecting the
equipment to the power source.
• Three days before during some rounds by administration
Ken was asked about having his coffee at the desk. Ken
apologized and removed it because he was reminded by
the VP that the policy was no food or beverage at the desk.
• On this day Ken brought his coffee to the desk because
upon arrival the phones were ringing and no one was
answering.
• While Ken was entering in orders, a Physician drops 5
records on the desk – they slid and knocked over Ken’s
coffee.
• The coffee runs all over the desk into medical records and
down through the hole with the power cords. All the
computers and monitors pop then go off.
Other Facts
• Electrical Safety is a mandatory annual
educational program and condition of
employment.
• Ken had been told multiple times not to have his
coffee at the desk. Ken understood the risk of
damaging our paper records however never
considered electrical damage as a risk.
• On the day of the event Ken had been called in
on his day off to cover a sick call. He came to
the unit and found the phone ringing on several
lines because no one was answering the phone.
• Ken stated he just started to work and forgot he
had his coffee on the desk.
Duty to Avoid Causing
Unjustifiable Risk or Harm
Was it the
employee
purpose to
cause harm?
Did the
employee
knowingly
cause harm?
NO
Did the behavior
represent a
substantial and
unjustifiable risk?
NO
YES
Did the employee
choose the
behavior?
Coach Employee and
conduct further ARB
investigation.
YES
Should the
employee have
know they were
taking a S&U risk?
NO
Did the employee
consciously
disregard this
substantial and
unjustifiable risk?
Case #3
• Ben has been working as a Registrar for about a
year and a half.
• Ben sees a friends name on the census.
• During a lull in registration Ben accesses the
EMR and checks on his friends condition.
• 2 days later his manager receives a report from
IS on EMR activity from her department. She
cross checks this information with registration
activity. She notes that there is a discrepancy
between the two reports.
• The manager calls Ben into her office to inquire
about his activity in the EMR.
Other Facts
• Ben has gone through the organizations
orientation and HIPAA training.
• Ben explained to his manager that this
friend is like his brother so he saw no
harm in checking in on him.
Duty to Produce an Outcome
Was the duty to
produce an
outcome known
to the employee?
*Social Benefit –
Would the greater
good be served?
Y
E
S
Y
Was it possible E
to produce the S
outcome?
**The outcome in this case
is protection of patient
privacy – do patients
expect privacy?
*Did the
social benefit
exceed the
risk?
NO
**Is the rate of
failure to produce
the outcome
within the
expectations of
those to whom the
duty is owed?
Assist employee
in producing
better outcomes
or Consider
Punitive Action.
Case #4
• Susan is the Nurse Manager of the Med/Surg Unit.
• Susan has recently participated in a patient safety
program that discussed Just Culture and improving
staff accountability to P&P’s designed to protect
patients.
• She decided to block out time to observe staff on the
unit. She doesn’t believe her staff is disregarding
policies and wants to reassure herself.
• She observes Kelly a nurse with 15 years experience
and 10 years at this hospital hanging IV fluids and
medications. She does not see Kelly verifying the
Patient ID or double checking against the Medication
Administration Record.
• As Kelly walks from the Med room to the patient room
she is stopped 3 times with questions from other staff.
Other Facts
• Susan retrieved the Med Administration record
and went into the patient room to verify the
correct IV’s were hung – they were.
• Susan went back to the Policy on Medication
Administration and found that the Standard was
to check meds in the med room, leave
medications in original packing until at bedside
and take the Medication Administration Record
to the bedside for a second check. Also using
the Med Administration Record as a tool in the
Patient ID check.
• Susan now plans a random day and block of
time each week for similar observations.
• Susan calls Kelly to the office for a discussion.
Duty to Follow a Procedural Rule
Was the duty to
follow the rule
known to the
employee?
YES
Was it
YES
possible to
follow the
rule?
Did the
employee
knowingly
violate the
rule?
YES
Did the
social benefit
exceed the
risk?
NO
Coach employee
and conduct further
at-risk behavior
investigation.
Social Benefit –
Would the greater
good be served?
Did the employee
have a good faith
but mistaken belief
that the violation
was insignificant or
justified?
Questions?